Provider Demographics
NPI:1275678195
Name:VANDIVER, JONAH RB (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONAH
Middle Name:RB
Last Name:VANDIVER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7104 S SHERIDAN
Mailing Address - Street 2:SUITE 8
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133
Mailing Address - Country:US
Mailing Address - Phone:918-492-1917
Mailing Address - Fax:918-492-4538
Practice Address - Street 1:7104 S SHERIDAN
Practice Address - Street 2:SUITE 8
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133
Practice Address - Country:US
Practice Address - Phone:918-492-1917
Practice Address - Fax:918-492-4538
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK53921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice